From the Guidelines
For a patient with a nosebleed who is taking Xarelto (rivaroxaban) and has a PROTIME of 23.4 and INR of 2.1, the most appropriate management is to apply direct pressure to the anterior portion of the nose and consider administering andexanet alfa, a specific reversal agent for rivaroxaban, as per the 2020 ACC expert consensus decision pathway 1. The patient's elevated INR of 2.1 indicates an increased anticoagulation effect, although this is less relevant for direct oral anticoagulants like Xarelto than for warfarin. According to the 2020 ACC expert consensus decision pathway, for a patient taking a FXa Inhibitor like rivaroxaban, andexanet alfa should be administered if available 1. Some key points to consider in the management of this patient include:
- Applying direct pressure to the anterior portion of the nose by pinching the soft part of the nostrils together continuously for 10-15 minutes while having the patient sit upright and lean slightly forward.
- Applying a cold compress to the bridge of the nose.
- Considering the use of topical vasoconstrictors like oxymetazoline nasal spray if bleeding persists.
- Temporary discontinuation of Xarelto may be necessary after consulting with the prescribing physician.
- Administering andexanet alfa, a specific reversal agent for rivaroxaban, as per the 2020 ACC expert consensus decision pathway 1. It is also important to investigate the underlying cause of the nosebleed, as it could be due to local factors like dryness or systemic issues related to anticoagulation, as suggested by the clinical practice guideline on nosebleed (epistaxis) 1.
From the Research
Patient Profile
- The patient is experiencing a nose bleed (epistaxis) while on Xaralto (rivaroxaban), a direct oral anticoagulant.
- The patient's PROTIME is 23.4 and INR is 2.1, indicating an elevated international normalized ratio.
Management of Epistaxis
- According to 2, most nosebleeds are not life-threatening and can be managed conservatively.
- However, hospital admission, referral to an otolaryngologist, and/or blood transfusion may be necessary in some cases.
- The management of epistaxis in patients on direct oral anticoagulants, such as Xaralto, is comparable to those on vitamin K antagonists, such as warfarin, with no significant differences in terms of age, sex, vital signs, bloodwork, or location of bleeding 3.
Reversal of Anticoagulation
- In cases of major bleeding, such as epistaxis, reversal of anticoagulation may be necessary.
- Prothrombin complex concentrates (PCCs) have been shown to be effective in reversing warfarin anticoagulation and normalizing INR 4, 5.
- However, the use of PCCs in patients on direct oral anticoagulants, such as Xaralto, is not well established, and further studies are needed to determine their efficacy and safety in this setting.
Monitoring and Treatment
- Close monitoring of the patient's INR and vital signs is necessary to determine the best course of treatment.
- The patient's INR of 2.1 is elevated, indicating an increased risk of bleeding, and treatment should be tailored to reduce this risk.
- According to 6, the treatment of epistaxis should be individualized, taking into account the patient's underlying medical conditions, medications, and other factors.